PRACTICAL APPLICATIONS
Decision Making in Gingival Recession Treatment: Scientific Evidence and
Clinical Experience
Giulio Rasperini,* Raffaele Acunzo,* Enrico Limiroli*
Focused Clinical Question: What are the key
considerations for selecting the best surgical approach
in mucogingival plastic surgery?
Summary: Treatment of gingival recession has
become an important therapeutic issue due to the in-
creasing number of cosmetic requests from patients.
The dual goals of mucogingival treatment include com-
plete root coverage, up to the cemento-enamel junc-
tion, and blending of tissue color between the treated
area and non-treated adjacent tissues. Even though
the connective tissue graft is commonly considered
the "gold standard" for treatment of recession defects,
it may not always be the best surgical option for every
case.
Conclusions: Under non-experimental condi-
tions, all root coverage procedures may be effective in
terms of complete root coverage and excellent esthetics.
Careful analyses of patient- and defect-related factors,
however, are key considerations prior to selecting an ap-
propriate surgical technique. Clin Adv Periodontics
2011;1:41-52.
Key Words: Connective tissue graft(s); gingival recession;
mucogingival surgery; periodontitis; plastic surgery,
periodontal.
Background
In periodontal practice, root coverage requires daily
clinical decisions. Randomized clinical trials support the
potential clinical value of all proposed mucogingival
plastic surgery techniques, both in terms of mean (MRC)
and complete root coverage (CRC), but fail to demon-
strate a clear superiority of any of the tested surgical
procedures.1,2 In addition, the clinical trials do not
provide clear guidance on when to use the different
procedures.
While concerns about facial appearance have obsessed
humans for centuries, the systematic assessment of esthetic
outcomes after surgical treatment of gingival recession is
a relatively recent proposal.3,4
*Unit of Periodontology, Dental Clinic, Department of Surgical,
Reconstructive and Diagnostic Science, Foundation IRCCS, Ca’ Granda
Policlinico, University of Milan, Milan, Italy.
Submitted December 9, 2010; accepted for publication February 1, 2011
doi: 10.1902/cap.2011.100002
The ultimate goal of root coverage procedures should be
complete coverage of the recession defect with a pleasing
color and tissue blend between the treated area and adja-
cent tissues, thereby achieving both biologic and esthetic
success. Thus, it is important to select the most predictable
and easy-to-perform surgical technique according to a care-
ful evaluation of the following factors:
1. Patient;
2. Single or multiple gingival recession defects;
3. Mucogingival defects localized in esthetically or non-
esthetic sensitive sites;
4. Defect anatomic morphology (amount of keratinized
tissue, periodontal biotype, and vestibule depth);
5. Ability to enhance periodontal wound healing and sta-
bilize the flap with optimal suture technique;
6. Biomaterials (connective tissue graft [CTG], enamel
matrix derivative, acellular dermal matrix).
Factors Affecting Complete Root
Coverage
Miller Class
Miller’s classification5 is based on morphologic evaluation
of the injured periodontal tissue, giving the diagnosis of the
severity of gingival lesions and the prognostic evaluation of
the treatment. According to this classification system,
which is still the most widely used, the loss of interproximal
bone (Class III and IV) is identified as a condition involved
in preventing CRC.
Post-Surgical Position of Gingival Margin (GM)
Soft tissue healing pattern after root coverage procedures
is usually linked to a shrinkage of the surgical wound. The
location of the GM relative to the cemento-enamel junc-
tion (CEJ) after the surgery seems to affect the proba-
bility of CRC;6 the more coronal the GM after suturing,
the greater the probability of achieving CRC. A coronal
displacement of 2 mm of the GM relative to the CEJ is
suggested.
Flap Tension
Enhanced periodontal wound healing is one of the most im-
portant issues for the clinical success of root coverage pro-
cedures. Even considering the different abilities of various
surgeons in tissue management, attention to blood supply
and suturing technique may influence the clinical outcome.
In particular, the use of surgical approaches that make the
Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 41
P R A C T I C A L A P P L I C A T I O N S

flap passive plays a major role in enhancing an optimal
wound healing to achieve an adequate coronal displace-
ment of the flap. Pini Prato et al.7 showed that the greater
the flap tension (suggested flap tension should not exceed
4 g), the less successful the recession improvement. Thus,
periosteal incisions should be used to eliminate tension
from the flap, and in the maxillary jaw, the periosteal inci-
sion should also include careful dissection of the muscle in-
sertions from the flap.
Cemento-Enamel Junction Predetermination
CRC is not always achievable, even in gingival recession
with no loss of interproximal attachment and bone. The
CEJ is the most widely used reference parameter to evaluate
root coverage results; however, such conditions as 1) cervi-
cal abrasion, 2) traumatic loss of the tip of the interdental
papilla, 3) tooth rotation, and 4) tooth extrusion with or
without occlusal abrasion may lead to diagnostic mistakes

Flap Thickness
The survival of the flap, and particularly the marginal gin-
giva, depends on the residual vascular system after surgical
incisions. Because of the caudo-cranial pattern of vascular-
ization, we suggest a full-thickness dissection, when possi-
ble, to avoid interrupting the supraperiosteal vessels that
enhance the survival of the flap on the avascular root sur-
face. Thus, the thicker the flap, the greater the vasculariza-
tion of the marginal gingiva and the probability of CRC
(suggested flap thickness >0.8 mm).8

Interdental Papilla Height

According to Saletta et al.,9 CRC is more likely to be
achieved in sites with a lower height of interdental papilla.
Olsson et al.10 demonstrated that individuals with a long-
narrow form of the central incisors (N biotype, scalloped-
thin) show a thin free gingiva, a narrow zone of gingiva,
and a wider height of the interdental papilla, while indi-
viduals with short-wide crowns (W biotype, flat-thick)
show a thicker free gingiva, a wider zone of keratinized
tissue, and a lower papilla height. Thus, it is possible that
the thicker gingiva of the flat-thick biotype allows
a thicker flap, which may result in a greater success rate
of CRC.

FIGURE 2 CAF procedure: suggested flap design in esthetic area. When

FIGURE 1 CAF procedure: flap design. Perform two horizontal beveled
incisions (a), mesial and distal to the recession defect, and an intrasulcular
incision (b). Execute two beveled oblique incisions (c) coming from the two
horizontal incisions, extending to the alveolar mucosa. Locate the two
horizontal incisions at a distance equal to the recession depth plus 1/2 mm
from the tip of anatomic papillae (AP) to predefine the surgical papillae (SP).
a ¼ horizontal incision; b ¼ intrasulcular incision; c ¼ vertical releasing
incision; REC ¼ recession depth.
a single recession-type defect is present in the esthetic area, we suggest
using an envelope flap technique, avoiding vertical releasing incisions to
reduce the probability of scar tissue formation. To facilitate the coronal
repositioning of the flap, make a horizontal incision that extends
mesiodistally to include three teeth. The horizontal incision of this modified
envelope technique consists of oblique submarginal incisions in the
interdental areas, which continue the intrasulcular incision at the recession
defect. Locate the starting point of oblique incisions at a distance from the
tip of the anatomic papilla equal to the recession depth plus 1/2 mm. A
number of disadvantages of this surgical technique can be pointed out: the
need to involve healthy adjacent teeth in the procedure and the smaller
dimension of the flap. 2a before surgery; 2b after surgery; 2c flap design.
REC ¼ recession depth; SP ¼ surgical papillae.

42 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions

FIGURE 3 CAFþCTG procedure: suggested flap design and harvesting
technique. Using a trap door technique (a) to harvest the CTG will allow
a primary wound closure of the donor palatal site, reducing patient
postoperative morbidity. Secure the graft over the exposed root surface
using a resorbable sling suture passing through the connective tissue of the
interdental papilla. 3a CTG harvesting from palate; 3b suture of the graft; 3c
6-month postoperative evaluation.
preventing CRC. Thus, in such clinical conditions, the line
of root coverage may be considered the clinical CEJ, be-
cause it may substitute for the anatomic CEJ when it is
no longer clinically visible or when ideal conditions to ob-
tain CRC are not fully represented.11,12
Rasperini, Acunzo, Limiroli
P R A C T I C A L A P P L I C A T I O N S
FIGURE 4 DPF procedure: flap design. Mucogingival defect affecting
tooth #11. An inadequate amount of keratinized tissue is present apically to
the recession, and the presence of well-represented interdental papilla
suggest a double papillae procedure. 4a baseline; 4b DPF; 4c 12-month
follow-up.
Preparation of Exposed Root Surface
To the best of our knowledge, no study has been reported in
the literature that shows one technique to be superior to all
others. The clinician may treat the exposed root surface
mechanically, by means of curets, sonic devices, polishing
or rotary instruments, or chemically using tetracycline,
sodium hypochlorite, or EDTA. According to our clinical
Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 43
P R A C T I C A L A P P L I C A T I O N S

FIGURE 6 LAF procedure: flap design. 6a Flap design and areas needing
to be deepithelized. An adequate amount of keratinized tissue is located
FIGURE 5 DPFþCTG procedure: surgical technique. To modify the quality
distally to the canine; 6b the LAF plus CTG correctly repositioned upon the
and amount of keratinized tissue over the exposed root surface, a DPF in
exposed root surface and stabilized with sutures; 6c 3-month follow-up.
conjunction with a CTG is performed. Use a trap door technique (Figure 3a)
as described previously to harvest the CTG and secure the graft over the
exposed root surface using a resorbable sling suture passing through the
connective tissue of the interdental papilla. 5a baseline; 5b CTG positioned
on the root surface; 5c 12-month follow-up.

Moreover, to avoid damaging any connective tissue

experience, we suggest using simple root preparation proce- fibers still embedded in cementum, it might be convenient
dures such as scaling and root planing with sonic devices and to prepare the exposed root surface prior to raising the flap,
curets. The need to flatten prominent roots may represent especially if a mechanical root preparation procedure is to
a clinical indication for the use of rotary instruments. be used.

44 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
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Restorative Approach in Mucogingival

Therapy
Gingival recession may be associated with dental abrasion
due to toothbrushing or cervical caries. In this situation,
the lack of a definable anatomic CEJ may present clinicians
with difficulties during the diagnostic phase that prevent
complete coverage of the exposed root surface. A classifica-
tion of such dental defects has been recently proposed by Pini
Prato et al.13 In cases where there is an identifiable CEJ, we
suggest predetermining the line of root coverage as described
by Zucchelli et al.11 and treating the portion of the tooth cor-
onal to the CEJ using a restorative approach. To avoid dam-
agingthegingivalmargin, wesuggestrestorationofthedental
abrasion prior to the surgical phase or during the surgery.

Treatment Strategy
Gingival recession treatment can no longer be considered
as a single treatment approach. In fact, there is evidence
to consider mucogingival plastic surgery as a multifactorial
treatment approach comprising careful selection of pa-
tients (see Decision Tree 1) and defects, different surgical
techniques, many suturing approaches, and various types
of adjunctive materials. All the cited components should
be variously combined to develop different treatment strat-
egies with different degrees of technical difficulties (see
Decision Tree 2).

Clinical Condition 1: Coronally Advanced Flap

(CAF) – Table 1
Selection of surgical flap
A distance from GM to mucogingival junction (MGJ) of at
least 2 mm should be present to enhance the stability of the
surgical flap after suturing. A CAF procedure alone should
be performed when a thick and flat periodontal biotype is
present to avoid a relapse. A moderate or deep vestibule
will allow coronal displacement of the flap without ten-
sion; a shallow vestibule does not prevent the use of a
CAF technique but requires an extensive partial-thickness

FIGURE 7 Multiple gingival recessions: surgical technique 7a Flap design;

7b multiple gingival recessions affecting teeth #4-6 (note the amount of
keratinized tissue apically to tooth #14 equal to 1.5 mm); tooth #4 is
extruded; 7c the horizontal incision of the flap consists of oblique
submarginal incisions in the interdental areas, which continue with the
intrasulcular incision at the recession defects. The oblique incisions must
be drawn starting from the mesial and distal side of the tooth to be treated
at a distance from the tip of the anatomic papilla equal to the recession
depth plus 1/2 mm; 7d the envelope flap is raised with a split-full-split
approach in the coronal-apical direction. Deepithelize the anatomic papilla
and mobilize the flap with a sharp dissection into the vestibular lining
mucosa; 7e displace coronally the flap and suture with sling suturing
technique; 7f 3 months postoperatively tooth #4 presents a residual
exposed root surface due to the extrusion condition; the patient’s
perception of an unpleasant esthetic result may be avoided by predeter-
mining the line of root coverage and performing a restoration of the portion
of the root that will not be completely covered. Moreover, the non-optimal
overall esthetic result due to the presence of visible tissue merging lines
can be corrected by performing a gingivoplasty at the end of the tissue
maturation period, about 3 to 6 months after the surgical phase.

Rasperini, Acunzo, Limiroli Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 45
P R A C T I C A L A P P L I C A T I O N S
dissection apically to the MGJ to make the flap tension
free.
Suggested surgical management
The surgical procedure was originally described by Allen
and Miller14 in 1989, and further modifications have been
proposed over the years. Perform a horizontal incision and
two beveled and slightly divergent releasing incisions
(Fig. 1). Using a small periosteal elevator, raise a full-thick-
ness flap and treat the exposed root surface with thorough
scaling and root planing using curets and/or ultrasonic de-
vices (Video 1: root surface conditioning by means of root
planing). Deepithelize the anatomic papilla (Video 2: ana-
tomic papilla deepithelization using a surgical blade [15c];
Video 3: use scissors to remove all the epithelium when the
roots are prominent) and expose the underlying connective
tissue. Extend the dissection of the flap apically to the MGJ
proceeding with a split-thickness approach (Video 4: re-
lease residual muscle tension, keeping the surgical blade
[15] parallel to the flap); pay close attention to releasing
the residual muscle tension as this will enhance the coronal
displacement of the flap (Video 5: cover the recession defect
only when a completely passive coronal displacement of
the flap can be achieved). Advance the flap coronally using
a sling suture technique and single interrupted sutures to
close the releasing incisions.
Surgical advice
1. Locate the horizontal incision at a distance from the
tip of anatomic papilla equal to recession depth
þ 1/2 mm (Fig. 1).
46 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011
DECISION TREE 1 Selection of the patient.
Adapted with permission from Quintessence Pub-
lishing Co. (In: Cortellini P, Bowers GM. Periodontal
regeneration of intrabony defects: An evidence-
based treatment approach. Int J Periodontics Re-
storative Dent 1995;15:128-145.) According to the
evidence, patients with <15% of sites presenting
with plaque and residual infection, non-smokers, with
a high degree of compliance, and systemically
healthy are the best candidates for root coverage pro-
cedures. FMPS ¼ full-mouth plaque score; FMBS ¼
full-mouth bleeding score.
2. Avoid making releasing incisions across the MGJ dur-
ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain.
3. Try to avoid releasing incisions when recession defect
is located in esthetic area (Fig. 2).15
Clinical Condition 2: Coronally Advanced Flap þ
Connective Tissue Graft (CAFþCTG) – Table 2
Selection of surgical flap
A distance from GM to MGJ of at least 2 mm should be
present to enhance the stability of the surgical flap after
suturing. A CAF procedure in conjunction with a CTG is
the technique of choice when a thin and scalloped peri-
odontal biotype is present, so that both the amount and
quality of marginal soft tissue may be appropriately trans-
formed. In the case of a thick biotype, the placement of
CTG can create an impaired esthetic due to irregular gin-
gival profile or scar tissue.4 A moderate or deep vestibule
will allow coronal displacement of the flap without ten-
sion; a shallow vestibule does not prevent the use of
a CAFþCTG technique but requires an extensive partial-
thickness dissection apical to the MGJ to make the flap ten-
sion free.
Suggested surgical management
Langer and Langer18 introduced the use of subepithelial
CTGs for root coverage, and several modifications to the
original technique have been published over the years. Per-
form the CAF procedure as described above. Harvest the
Decision Making in Gingival Recessions

CTG from the palate using a trapdoor technique (Fig. 3a);
be sure to preserve a band of keratinized tissue at least 1
to 2 mm from the palatal GM. To keep the graft moist,
place it on gauze soaked in physiologic saline solution.
Close the palatal wound with interrupted suture. Suture
the CTG at the recipient site using resorbable sling sutures
passing through the interdental papilla connective tissue
(Fig. 3b).
Surgical advice
1. Locate the horizontal incision at a distance from the
tip of anatomic papilla equal to recession depth þ 1/2
mm (Fig. 1).
2. Avoid making releasing incisions across the MGJ dur-
ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain.
3. Try to avoid releasing incisions when recession
defect is located in esthetic area (Fig. 2).15 A de-
Rasperini, Acunzo, Limiroli
P R A C T I C A L A P P L I C A T I O N S
DECISION TREE 2 Selection of the treatment
strategy. Root coverage procedure should be
selected according to a careful anatomic analysis
of the recession defect; this will allow a higher
probability of complete root coverage. LAF, laterally
advanced flap; LAFþCTG ¼ laterally advanced flap
þ connective tissue graft; KT ¼ keratinized tissue;
S ¼ shallow vestibule; M ¼ moderate vestibule; D ¼
deep vestibule.
epithelialized graft technique can be used instead of
a trap-door procedure to reduce the chair time and
simplify the harvesting procedure.
4. Close the palatal wound using collagen sponges (to
enhance secondary intention wound healing) and
criss-cross suture technique after a deepithelialized
graft procedure.
Clinical Condition 3: Double Papillae Flap
(DPF) – Table 3
Selection of surgical flap
To perform a DPF technique, an alternative keratinized tis-
sue donor-site must be represented by adjacent interdental
papillae. Periodontal biotype should be classified as thick
and flat. This surgical technique is not affected by vestibule
Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 47
P R A C T I C A L A P P L I C A T I O N S

TABLE 1 Key Point References for CAF Technique

Reference Aim Findings Predictor

Olsson et al.10 Periodontal biotype Thin: high triangular-shaped interdental papilla, thin and narrow KT. Thin ¼ recession
(1993) classification Thick: small interdental papilla, wide and thick KT. Thick ¼ pocket

Baldi et al.8 Thickness flap Flap thickness is a significant predictor for root coverage after CAF Thickness >0.8 mm
(1999) procedure. enhances CRC

Pini Prato et al.7 Flap tension The higher the flap tension, the smaller the recession reduction. Tension <4 g enhances
(2000) CRC

Saletta et al.9 Papilla height and CRC is not correlated to the papilla area but to papilla height. Lower papilla height
(2001) area enhances CRC

Pini Prato et al.6 Distance between The location of GM relative to the CEJ following CAF procedure seems to GM-CEJ ‡2 mm
(2005) GM and CEJ affect CRC. enhances CRC

Hwang and Thickness flap A positive association exists between flap thickness and MRC and CRC.
Wang16 (2006)

Zucchelli et al.11 CEJ determination Localization of CEJ is influenced by tooth rotation, extrusion, and cervical
(2006) abrasion.

Santamaria Local anatomy The depth of non-carious cervical lesion may influence the reduction of Reduced root convexity
et al.17 (2010) gingival recession when CAF is performed. enhances CRC

CRC ¼ complete root coverage; MRC ¼ mean root coverage; GM ¼ gingival margin; KT ¼ keratinized tissue; CEJ ¼ cemento-enamel junction.

TABLE 2 Key Point References for CAFþCTG Technique

Reference Aim Findings

19
Cairo et al. Outcome of CAF CTG or EMD in conjunction with CAF enhances the probability of obtaining CRC in Miller Class I and II
(2008) procedure single gingival recession.

Cortellini et al.20 CAF versus CAFþCTG Adjunctive application of CTG under a CAF increases the probability of achieving CRC in maxillary Miller
(2009) Class I and II defects.

Zucchelli et al.21 Morbidity and clinical No differences are demonstrated in the postoperative pain and root coverage using CAFþCTG or CAF
(2010) outcomes plus deepithelized gingival graft.

CTG ¼ connective tissue graft; EMD ¼ enamel matrix derivative; CAF ¼ coronally advanced flap.

TABLE 3 Key Point References for DPF Technique

Reference Aim Findings Predictor

Kerner et al.23 Factors that may affect the clinical outcome in Under non-experimental conditions, root Miller Class, maxillary
(2008) non-experimental patients coverage procedures are effective. teeth, smoking, donor-site

TABLE 4 Key Point References for DPFþCTG Technique

Reference Aim Findings

Harris et al.24 (2005) Compare CAF, DPF, and tunneling technique All three techniques are effective in obtaining CRC.

48 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 Decision Making in Gingival Recessions
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TABLE 5 Key Point References for LAF Technique

Reference Aim Findings

Zucchelli et al.26 Surgical The laterally moved CAF is very effective in treating isolated gingival recessions. The ideal gingival conditions must
(2004) technique be present lateral to the defect to be treated.

TABLE 6 Key Point References for Multiple Gingival Recessions Technique

Reference Aim Findings

Zucchelli and De Surgical The proposed surgical technique is effective for the treatment of multiple gingival recessions affecting teeth in
Sanctis27 (2000) technique esthetic areas of the mouth. This result may be achieved irrespective of both the number of recessions
simultaneously treated and the presence of minimal keratinized tissue prior to surgery.

Zucchelli and De Long-term At the 5-year examination, 94% of the initially exposed root surfaces are still covered, and 85% of the treated
Sanctis28 (2005) outcome recession defects showed CRC. CRC in all recessions is maintained in 15 of 22 patients (68%).

depth due to the small coronal displacement required to
cover the recession defect.
Suggested surgical management
Cohen and Ross22 introduced the method in which bilateral
interdental papilla is used as donor tissue for localized root
coverage. Perform a V-shaped incision at the buccal aspect
of the involved tooth, with an internal bevel on one side of
the V-shaped incision and an external bevel on the other. Make
horizontal and vertical incisions as described for the CAF tech-
nique, locating the horizontal incisions closer to the tip of in-
terdental papilla as much as possible to include more tissue in
the flap. Raise a full-thickness flap and condition the root sur-
face by means of scaling and root planing using curets and/or
sonic devices. Suture together the two surgical papillae with
interrupted sutures (Fig. 4b). Extend the dissection of the flap
apically to the MGJ, proceeding with a split-thickness ap-
proach (Video 4: release residual muscle tension, keeping
the surgical blade [15] parallel to the flap) and paying atten-
tion to release the residual muscle tension (Video 5: cover the
recession defect only when a completely passive coronal dis-
placement of the flap can be achieved). Cover the recession
defect using a sling suture technique and use single interrupted
sutures to close the releasing incisions (Fig. 4b).
Surgical advice
1. Avoid making releasing incisions across the MGJ dur-
ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain.
2. Once the interdental papillae have been dissected, join
them using interrupted sutures before proceeding with
the next steps of the surgical procedure; this will make
flap manipulation simpler.
Clinical Condition 4: Double Papillae Flap þ
Connective Tissue Graft (DPFþCTG) – Table 4
Selection of surgical flap
As described for the DPF technique, an alternative kerati-
nized tissue donor site must be represented by adjacent
interdental papillae to perform DPF in conjunction with
CTG. Periodontal biotype should be classified as thin
and scalloped. This surgical technique is not affected by
vestibule depth due to the small coronal displacement re-
quired to cover the recession defect.
Suggested surgical management
Clean the root surface, perform the surgical flap, and harvest
the CTG as described previously (Fig. 5).
Surgical advice
1. Avoid making releasing incisions across the MGJ dur-
ing the initial phase of the surgical procedure; this will
reduce postoperative swelling and pain.
2. Once the interdental papillae have been dissected, join
them using interrupted sutures before proceeding with
the next steps of the surgical procedure; this will make
flap manipulation simpler.
3. A deepithelialized graft technique can be used instead
of a trap-door procedure to reduce the chair time and
simplify the harvesting procedure.
4. Close the palatal wound using collagen sponges (to en-
hance secondary intention wound healing) and criss-
cross suture technique after a deepithelialized graft
procedure.
Clinical Condition 5: Laterally Advanced
Flap (LAF) – Table 5
Selection of surgical flap
To perform a LAF technique, an alternative keratinized tis-
sue donor site must be represented by adjacent teeth. Peri-
odontal biotype should be classified as thick and flat. This
surgical technique is not affected by vestibule depth due to
the small coronal displacement required to cover the reces-
sion defect. However, a shallow or moderate vestibule may
require more surgical operator skill to obtain a completely
tension-free flap; an inadequate dissection of periosteum
and muscle insertions may lead to a relapse.

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Suggested surgical management
LAFs have been widely used since Grupe and Warren25 in-
troduced this method for the treatment of localized gingi-
val recession. In this procedure, the adjacent keratinized
gingiva is positioned laterally and the exposed root surface
covered. Over the years, several further modifications of
this technique have been proposed to avoid bone loss
and gingival recession on the donor site, the most frequent
adverse events related to this surgical procedure. Recently
Zucchelli et al.26 proposed a modified approach that ap-
pears to be more reliable and safe (Fig. 6).
Surgical advice
1. According to muscle insertion orientation, the LAF
should be preferably performed when the donor site
is localized mesial to the gingival recession defect.
2. When the flap is moved in the distal-mesial direction,
another short horizontal incision should be performed
at the most apical extension of the distal vertical re-
leasing incision in order to facilitate mesial mobiliza-
tion of the flap.
3. Use collagen sponges, stabilized with criss-cross su-
tures, to promote wound healing of the keratinized
tissue donor site adjacent to the recession defect.
Clinical Condition 6: Laterally Advanced Flap þ
Connective Tissue Graft (LAFþCTG)
Selection of surgical flap
As described for the LAF technique, an alternative kerati-
nized tissue donor-site must be available at adjacent teeth
to perform LAF in conjunction with CTG. The periodontal
biotype and vestibule depth for the LAFþCTG should
be the same as described for the laterally advanced flap
alone.
Suggested surgical management
Clean the root surface, perform the surgical flap, and har-
vest the CTG as described previously.
Surgical advice
1. According to muscle insertion orientation, the LAF
should be preferably performed when the donor site
is localized mesial to the gingival recession defect.
2. When the flap is moved in the distal-mesial direction,
another short horizontal incision should be performed
at the most apical extension of the distal vertical re-
leasing incision in order to facilitate mesial mobiliza-
tion of the flap.
3. Use collagen sponges, stabilized with criss-cross su-
tures, to promote wound healing of the keratinized
tissue donor site adjacent to the recession defect.
4. A deepithelialized graft technique can be used instead
of a trap-door procedure to reduce the chair time and
simplify the harvesting procedure.
5. Close the palatal wound using collagen sponges (to en-
hance secondary intention wound healing) and criss-
50 Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011
cross suture technique after a deepithelialized graft
procedure.
Clinical Condition 7: Multiple Gingival
Recessions – Table 6
Another factor to consider in the surgical treatment of gin-
gival recession is that mucogingival-type defects are very
seldom localized to a single tooth. More frequently, gingi-
val recessions affect groups of adjacent teeth. Thus, to min-
imize the number of surgeries and to optimize the esthetic
result, all of the contiguous recessions should be treated si-
multaneously. Patient-related esthetic considerations
would suggest the use of a surgical technique that predict-
ably obtains CRC in all present recessions by using the soft
tissue adjacent to the defects.
Suggested surgical management
Zucchelli and De Sanctis27 proposed a new surgical ap-
proach for the treatment of multiple recession defects
(Fig. 7). This modified design of the envelope flap consists
of an oblique submarginal incision in the interdental area,
which continues with an intrasulcular incision at the reces-
sion defects.
Surgical advice
1. When performing an envelope-type flap, avoid verti-
cal releasing incisions to help maintain adequate
blood flow to the flap and reduce the formation of vis-
ible white scars.
2. Use ‘‘split-full-split’’ flap elevation, with full thickness
for that portion of the flap residing over the previously
exposed root surface, to increase the potential to
achieve CRC.
3. The absence of a wide zone of keratinized tissue apical
to the defects is not considered a limitation; a CTG
may be used at one single specific recession defect if
necessary.
4. Suture the flap using a sling suture technique passing
through the connective tissue of the anatomic papilla.
Conclusions
Due to an increasing public demand for cosmetic dentistry,
the treatment of gingival recession has become an important
therapeutic and esthetic issue for the contemporary peri-
odontal practice. While the efficacy of using CTGs to obtain
full coverage of root surface exposure is well supported in
the literature, this cannot be the only worthy treatment goal;
surgeons must also use their skills to fulfill the demand for
the improved esthetics their patients expect.
Furthermore, even as CTG is considered the gold stan-
dard treatment for single and multiple areas of recession,
a simpler, less invasive approach, such as a CAF, may yield
an equally acceptable result. Each clinical situation must
be evaluated to determine the most appropriate surgical
Decision Making in Gingival Recessions
 P R A C T I C A L A P P L I C A T I O N S

approach to achieve the esthetics expected by the patient. Acknowledgment

Therefore, to achieve the best clinical and esthetic success, The authors did not receive any financial support for this
a careful assessment of existing anatomic parameters, such study.
as the amount of keratinized tissue, the periodontal bio-
type, and vestibule depth, is a vital part of the surgical de- CORRESPONDENCE:
cision-making process. n Dr. Giulio Rasperini, Via XX Settembre, 119 - 29121 Piacenza, Italy. E-mail:
giulio@studiorasperini.it.

Rasperini, Acunzo, Limiroli Clinical Advances in Periodontics, Vol. 1, No. 1, May 2011 51
P R A C T I C A L A P P L I C A T I O N S
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